KNOW your BENEFITS. Do you have questions about your medical or prescription drug coverage?

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1 2015 BENEFITS GUIDE

2 We are pleased to announce that we will be renewing our medical and pharmacy benefit plans with Florida Blue for This Benefit Guide provides important information and details regarding your medical and pharmacy plans for services received on or after January 1, Please read carefully to ensure you select the right plan for your healthcare needs. KNOW your BENEFITS Do you have questions about your medical or prescription drug coverage? Florida Blue is here to help, call us at Monday Thursday 8am to 6pm and Fridays 9am to 6pm. Pharmacy Go generic generic medications cost less than brand name medications and in most cases they are just as effective. Remember, if a brand name medication is prescribed, the plan will provide the generic equivalent. If you refuse to take the generic and elect to take the brand medication instead, you will pay the brand drug copayment plus the retail cost difference between the generic and brand name medication. Covered Medications Be sure to review Florida Blue s Medication Guide to find out if your current prescription is covered. The Medication Guide will also help you determine what tier your prescription falls into in order to help determine your cost. You can also locate generic alternatives in the guide to help you save money. The Medication Guide can be found on Mail Order Fill your maintenance medications with Florida Blue s Mail Order Pharmacy through Prime Therapeutics. Visit for information on how to request a mail order prescription. ID Cards You will receive a new ID card this year, but it is important to remember your existing card is still valid. Please hang onto your current ID card until your new one arrives in the mail. If you need additional ID cards, you can register on Florida Blue s member website ( or call customer service to request additional cards. Did you know you can register for a personalized Florida Blue member web page at floridablue.com? You just need your member ID number to get started. Take advantage of online prescription drug tools, member discounts, health & wellness information, and much more. 1

3 Away From Home Care If you enroll in one of the HMO products, you will have access to certain health care services across the country. To meet the different health care needs of members and dependents who are away from home separate programs for short trips and long-term stays. For short trips, the BlueCard Program gives you access to doctors and hospitals in most locations, giving you the peace of mind that you ll always find the care you need. For longer trips (90 consecutive days or longer), the Away From Home Care Guest Membership program may be available for you and your covered dependents in most states. For eligibility information and specific locations where the Guest Membership program is available, please contact the customer service number indicated on your ID card. Wherever you go, whenever you need it, you have access to your Florida Blue personal health care information. As a member, you can log in anytime and find everything you need to know about your health plan, plus free tools and resources. All you need is your member number, located on your member ID card. Review your plan benefits and find out where you stand with your deductible. Find a doctor or hospital in your plan s network. View claim activity, status and history. Print a temporary ID card or request a new ID card. And much more! How to Save Blue365 You can save BIG on a wide variety of healthy products and services through our members-only discount program Blue365. Take advantage of exclusive discounts on fitness clubs, exercise equipment, contact lenses or glasses, and so much more! Register on when you receive your ID card and start saving! Care Consultants Planning an upcoming surgery or need help managing an ongoing condition? Contact a Care Consultant. Florida Blue s Care Consultants can help you navigate through the health care system and help you save money on your out-ofpocket expenses. Call Know Before You Go Don t pay more than you should Shop, compare and save money. You have choices when it comes to the cost of your health care. The quality and price of medical services can vary depending on where you go. Compare quality and cost before you go, and then decide what s best for your care. Cost estimates are based on your plan and where you stand with your deductible. To get cost estimates, simply log in at floridablue.com and select Compare Medical Costs under Tools. You can also compare costs on your prescription drugs by pharmacy and find cheaper alternatives. The benefit elections you make will be binding. You will be governed by the terms, provisions and restrictions of the plans in which you enroll. Generally, unless you experience a qualified life event, your elections will remain in effect for the entire plan (calendar) year. This document highlights changes and important information. Please be sure to read all of your open enrollment materials carefully for complete benefit information for For additional questions regarding benefits, physician network, claims or eligibility, please contact Florida Blue s Customer Service team toll-free at

4 2015 Benefit Summary Plan Name BlueCare HMO BlueOptions PPO BlueCare HDHP Plan Number Coverage In-Network Only In-Network Out-of-Network In-Network Only Deductible and Maximum Out-of-Pocket Deductible (DED) (Per Person/Family Aggregate) Individual $300 $750 $1,000 $1,500 Family $600 $1,500 $2,000 $3,000 Out of Pocket Maximum (Per Person/Family Aggregate) Includes Deductible, Coinsurance and Copayments (medical & rx) Individual $2,500 $6,000 $9,000 $5,000 Family $5,000 $12,000 $18,000 $10,000 Medical / Surgical Care by a Physician Office Services Family Physician $25 Copayment $30 Copayment $25 Copayment DED + 50% Specialist $35 Copayment $40 Copayment DED + 30% Physician Services at Hospital (Outpatient and Inpatient) Preventive Services Family Physician/ Specialist Medical / Surgical Care at a Facility Inpatient Hospital Facility (per admit) Outpatient Hospital Facility or Ambulatory Surgical Center (per visit) DED + 30% DED + 30% DED + 50% DED + 30% $0 Copayment $0 Copayment 50% $0 Copayment DED + 30% DED + 30% DED + 50% DED + 30% Emergency and Urgent Care Facility Charges (separate physician cost share may apply) Emergency Room Facility (per admit) $300 Copayment + 30% $300 Copayment + 30% $300 Copayment + 30% DED + 30% Urgent Care Centers $30 Copayment $35 Copayment DED + 50% $25 Copayment Ambulance $200 Copayment $200 Copayment $200 Copayment DED + 30% Diagnostic Testing (e.g., Lab, x-ray) Independent Clinical Laboratory $0 $0 DED + 50% $0 Diagnostic Testing Center $30 Copayment $35 Copayment DED + 50% DED + 30% Advanced Imaging (AIS) (MRI, MRA, PET, CT & Nuclear Medicine) Outpatient Therapy (60 visits per benefit period) In-Network Family Physician Specialist $300 Copayment $300 Copayment DED + 50% DED + 30% $35 Copayment $40 Copayment DED + 50% DED + 30% 3

5 2015 Benefit Summary cont. Plan Name BlueCare HMO BlueOptions PPO BlueCare HDHP Plan Number Coverage In-Network Only In-Network Out-of-Network In-Network Only Perscription Drugs Retail Generic $10 $10 DED + Coins $10 Preferred Brand $40 $40 DED + Coins $40 Non-Preferred Brand $75 $75 DED + Coins $75 Mail Order Generic $20 $20 Not Covered $20 Preferred Brand $80 $80 Not Covered $80 Non-Preferred Brand $150 $150 Not Covered $150 All plans cover Routine Vision and Hearing Exams when services are received by a participating physician. These services are covered 100% based on the below guidelines: Routine Hearing Exams covered annually for adults and children Routine Vision Exams for Adults (18 and older) every 24 months Routine Vision Exams for Children (under the age of 18) every 12 months Note: Eyeglasses and contact lenses and their fitting are excluded. Please refer to your Benefit Booklet for more detail. Referrals are not required to see a specialist on any of the plans offered but a Primary Care Physician (PCP) should be selected if you choose to enroll on one of the HMO plans. To select or change a PCP contact Florida Blue. This is not an insurance contract or Benefit Booklet. The above Benefit Summary is only a partial description of the many benefits and services covered by Blue Cross and Blue Shield of Florida, Inc., an independent licensee of the Blue Cross and Blue Shield Association. For a complete description of benefits and exclusions, please see Blue Cross and Blue Shield of Florida s Benefit Booklet and Schedule of Benefits; their terms prevail.the information contained in this proposal includes benefit changes required as a result of the Patient Protection And Affordable Care Act (PPACA), otherwise known as Health Care Reform (HCR). Please note that plan benefits are subject to change and may be revised based on guidance and regulations issued by the Secretary of Health and Human Services (HHS) or other applicable federal agency. In addition, the rates quoted within this proposal are based on the plan benefits at the time the proposal is issued and may change before the plan effective date if additional plan changes become necessary. Additionally, Interim rules released by the Federal Government February 2, 2010 require BCBSF to test all benefit plans to ensure compliance with the Mental Health Parity and Addiction Equity Act (MHPAE). Benefits and rates reflected in the proposal are subject to change based on the outcomes of the test. 4

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